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Monday, 9 June 2014

Carrying on
with our WCE 2014 highlights, let’s have a look at some of the research into
fertility issues and endometriosis. Reduced fertility is one of the major
problems faced by women with endometriosis, yet there are still many mysteries
surrounding how endometriosis affects fertility.

In order to
shed at least some light on the issue an Italian research team investigated how
ovarian endometriosis (endometrioma) can affect the viability of ovarian
follicles in women undergoing IVF. What they found was that follicles closer to
endometrioma showed higher levels of iron. Iron, of course, is important for
your body but in endometriomas iron accumulates in high amounts, probably due
to blood filling the inside of the cyst. These high levels of iron can be toxic
to anything close by, in this case, ovarian follicles. This leads to impaired
development of the follicle and perhaps partly explains why so many women with
endometrioma/s find it hard to conceive.

If you have
an endometrioma, chances are you’ll want surgery to remove it, but you’ll also
want to know what the risk of recurrence is and what factors influence that
risk. A team from Brazil looked at the records from 202 women undergoing
laparoscopic excision of endometrioma between and 2003-2012 and analysed those
records to see what influenced endometrioma recurrence. They found that the
overall rate of endometrioma recurrence was 16.4% and that factors such as age,
race, symptoms, exercise, number of children and type of surgical procedure had
no effect on recurrence rates. However, they found that having a cyst larger
than 6cm (which is pretty large) and stopping medical therapy after surgery significantly
increased the chance of endometrioma recurrence (although the abstract didn’t specify
which medical therapy was used). Because of the side effects associated with
some of the medical treatments for endometriosis, it is unsurprising some women
need to stop treatment. However, if stopping treatment means an increased risk
of disease recurrence, then more work needs to be put into ensuring other, more
tolerable medical options are made available.

Speaking of
IVF, some women who suffer with fertility issues may consider IVF as a means of
conception. It is therefore important for women with endo to know if their
condition may affect their IVF outcome. A group from France compared 291 women
with endo to 1316 women without to see what the effects, if any, endo made to
the delivery rates after undergoing IVF. What the researchers found was that,
in the women who had good ovarian stimulation response and high quality
embryos, the total cumulative successful delivery rate for fresh and frozen
embryos was 52.3% for women with endo and 45.8% for women without. Although
women with endo had lower rates of good ovarian stimulation, the overall
outcome was no different between women with and without endo. This suggests
that having endo (regardless of stage) may not impact the success of IVF.

Although it
appears that endo doesn’t affect the success of IVF, it would still be good to
have some way of improving IVF outcomes. A group from New Zealand has been conducting
a randomised, controlled trial to see if a drug called Lipiodol has any benefit
on IVF outcomes, as their initial tests showed this treatment improved the
fertility of women with endo much more than women who couldn’t conceive but
didn’t have endo. Lipiodol can normally be used for hysterosalpingography (a procedure used to determine the shape of the
uterus and fallopian tubes) and is injected into the uterine cavity so comes
into contact with the endometrium. The authors of this study think that
Lipiodol ‘bathes’ the endometrium, making it more receptive to a fertilized
egg. Their results are still very preliminary so should be met with cautious
optimism, but are still encouraging. The women who received IVF alone achieved
a live delivery in 22.7% of cases, but the women who had Lipiodol treatment
plus IVF achieved a live delivery 43.8%. These results are encouraging, but
we’ll have to wait until the clinical trials have been completed and the
results properly analyzed before drawing any firm conclusions.

Thursday, 5 June 2014

Let’s
continue our exploration through the World Congress on Endometriosis 2014 and we’re
going to delve into some of the research about what makes women with endo different
from those without and how this could give us clues as to what causes endo in
the first place.

A team from
Australia made an interesting discovery regarding stem cells and endometriosis.
You have probably heard about stem cells before, but why would they be of
interest in endometriosis? Stem cells are the precursors to the different types
of cells in your body and are mostly of use during the very early part of your
development when you were a foetus growing new organs. But they still have some
use as an adult, for example, inside the uterus there are a population of stem
cells that your body uses to regrow the endometrium after each menstruation,
which are unsurprisingly referred to as endometrial stem cells. If these cells
can grow endometrium and endometriosis is endometrium-like tissue, it becomes
clear how these stem cells could play a role in endometriosis. Some researchers
believe that genetic changes associated with endometriosis result in some
endometrial stem cells becoming displaced during embryo development, which go
on to produce endometriotic lesions as a girl approaches adolescence. Others
believe these stem cells are shed into the pelvic cavity by retrograde
menstruation (where the menstrual blood goes into the pelvic cavity) and implant
around the pelvis and then develop into endometriotic lesions.

This
investigation by the Australian team looked at the number of endometrial stem
cells in the blood, menstrual blood and peritoneal fluid of women with and
without endometriosis. What they found was that, although the amount of peritoneal fluid was similar
between the two groups, the number of viable endometrial stem cells in the
peritoneal fluid was massively higher in women with endo. So how did those
cells get there? Retrograde menstruation is a likely explanation, but they
found no difference in the amount of stem cells in the menstrual blood between
women with and without endo.It could be
that the immune system of women with endo doesn’t clear the refluxed stem cells
and they just accumulate or maybe there is some other way these cells are
getting into the pelvic cavity, at this moment nobody knows for sure.

Speaking of
peritoneal fluid, a group from the US and Brazil analysed the peritoneal fluid
looking for inflammatory factors that are related to endometriosis associated
pain. What they found was that dyspareunia (painful sex), non-cyclic pain and
infertility were not related to the inflammatory factors they were studying.
What they did find though was that certain inflammatory factors were associated
with dysmenorrhea (excessively painful periods). This has some potentially very
interesting implications, particularly as dysmenorrhea is the most common
symptom of endometriosis. This suggests that dysmenorrhea is caused by areas of
chronic inflammation around the sites of endometriosis regardless of stage or
location. If it were possible to find out how these inflammatory factors are
being produced and find a way to reduce the level of these factors, in the future
this could be a new way of treating the pain associated with endo.

Tuesday, 3 June 2014

It’s that
time again, that time when the best and brightest in the field of endometriosis gather
together in one place to share their collective experience and figure out where
the future of endometriosis research and treatment is going; all whilst
enjoying a caipirinha on the sunny beaches of Sao Paulo (us science types know
how to multitask). Although I managed to go to the previous WCE in France, unfortunately
I couldn’t make it this year, so instead of enjoying the glorious heat of the
Brazilian south I was enjoying the drizzly rain of the English northwest, oh
well. However, thanks to a friend, I did manage to get the book of abstracts
(which is basically a summary of all the talks, presentations and posters at
the conference) so I can give you a rundown of what’s been going on in the
field of endometriosis research now and in the future.

Before I
continue I must mention that the information I’ll be presenting here is taken only
from the abstracts, which as basic summaries of the research and not in depth
discussions and may or may not be taken from completed or peer-reviewed
research. Also because these are conference papers I can’t provide links to
source material as I normally would.

To start
with, just looking at the book is encouraging, over 400 pages of research into
all the many and varied aspects of endometriosis, which is broken down into
different subject matters, so I’ll start with genetics and endometriosis.

Genetics is
an important factor in endometriosis, mainly because we don’t really fully understand
how genetic changes contribute to endometriosis risk. A team from Sweden aimed
to examine indirectly the role genetics play, by looking at the rate of
endometriosis in twins. There are two different types of twins: monozygotic
(where both twins come from the same egg and are essentially genetically
identical) and dizygotic twins (where each embryo comes from a different egg
and can so each twin can be very different from the other). Of all the female
twins this research looked at they found that there was a much higher risk of
endometriosis if your monozygotic twin also had endometriosis. That certainly
seems to suggest that genetics plays a role in the origin of the disease. Of
course there are other factors at play too in determining endometriosis risk.
This team, after doing some calculations, found that in the women they studied,
genetics accounted for around half of the risk associated with endometriosis
and environmental factors accounted for the other half. Finding out what the
specific genetic and environmental factors are and how they increase or
decrease the risk of endometriosis, is an ongoing challenge for the future.

Several
other studies presented at the conference aimed to find out what these genetic
factors are. Our genetic material (our DNA) is a funny thing, it can change in
many different ways, some bits can swap, duplicate or be deleted all together
and sometimes specific changes can be associated with specific diseases. Other
research identified some of these specific changes associated with
endometriosis which may, in the future, might allow us to identify women at risk
of the disease with greater ease and hopefully give us to better understand the
way in which the disease works.

Of course
there are problems to consider, for example, are the genetic changes we see the
same across all women? One of the presentations from an international team
found that the genetic changes we know of so far are very similar between women
of European and Japanese ancestry, but we still have no information on women of
African, Chinese, Indian etc ancestry to compare them to. These types of studies
though require a great deal of time and money invested in them, so it may be a
while before we see a complete picture of the genetic risk associated with
endometriosis for women across the world.

Another
point to consider is the difference between types of endometriosis. One piece
of research from a Danish team found genetic alterations specific to deeply
infiltrating endometriosis. Therefore it could be that peritoneal, deeply
infiltrating and ovarian endo all have different genetic alterations (and different
genetic risks) associated with them. It’s good to know though there are people
actually looking into this and one day, maybe soon, we’ll have that complete
picture.

Endometriosis Update

Endometriosis is an enigmatic disease, little is known about its origins, but it affects the lives of millions of women around the world. Despite the apparent lack of advancement in the field of endometriosis research, progress is slowly being made. The problem is that this progress is very rarely reported accurately to the public in a way everyone can understand. This Blog aims to report what is going on in the area of endometriosis research in plain and simple terms, so that everyone can keep up to date. Updates will be pretty sporadic but I'll try to report items of interest as often as possible.